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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordina c No. 4862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S7— City/Town <br /> Owner's Name _ Phone _ <br /> Address City 0_4 . <br /> Contractor's Name License f#��/ Business Phone S { <br /> Contractor's Address 014 42 f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION,❑ <br /> WELL CHLORINATION C1 WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION LY PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> JWENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATJION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ <br /> DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL C SLurfwe Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ka I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done –� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c 1 f Grout�Sp ction prior to grouting and a final inspection. <br /> Signed Title: 15-C ��d_ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASIE I �y J <br /> Application Accepted By -- Dale <br /> Additional Comments: <br /> Phase li Grout Inspection pdffl Inspection 9r f✓ �'r� <br /> Inspection By Date Inspection By Date (/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re e/ed By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE b <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 'p- <br /> Received <br /> Received by Date Receipt No. Permit No. I nuance D to .. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />